In this study, we found that about one-third of women did not receive adequate follow-up care for marginally abnormal mammograms. Documentation of the follow-up plan by the physician and understanding of the follow-up plan by the patient were associated with higher rates of adequate follow-up. These findings highlight one of the most important quality issues related to the clinical encounter,21
as patient safety and satisfaction are jeopardized when the patient-physician communication regarding the follow-up of abnormal test results break down. Given the circulation of a newsletter to clinicians and the administration of a mammography-related baseline survey in this study, the follow-up rates in the typical clinical setting are likely even lower. These results, in conjunction with those from other studies,22 – 25
highlight the ongoing need to address this gap in quality. Fortunately, this issue is beginning to receive national attention. Studies have shown that both patients26
are concerned about this issue. The Agency for HealthCare Research and Quality (AHRQ),28
in a recent set of recommendations issued to patients on how to prevent medical errors, recommends to patients that “no news (on test results) is not good news,” suggesting that the results follow-up systems currently employed by our health care system are insufficient to protect patients’ safety.
Previous studies have identified that race, insurance status, socioeconomic factors, and other clinical variables may predict whether a patient receives the appropriate follow-up of abnormal test results. While these findings potentially enable us to target high-risk groups for intervention, these factors are not readily modifiable and intervention strategies born out of these findings are difficult to implement on a large scale. For example, providing monetary incentives to patients with abnormal Pap smears can indeed increase the adherence rate to the follow-up plan in economically poor populations,25
but these interventions are difficult to sustain long term. Also implicit in these interventions is the presumption that patient nonadherence is largely responsible for this gap in quality. Our results, we believe, offer a different perspective on the problem: patient factors alone do not account for the quality gap, and patient-doctor communication is a potential target for intervention.
We found that 2 apparently simple steps in the chain of patient-doctor communication events are independently predictive of the favorable outcome. First, we found that patients who reported being told that they needed follow-up for their abnormal mammogram result were more likely to receive it. This may suggest that patients who have a better understanding of their care plans receive better quality care. Unfortunately, current practice environments may not allow physicians sufficient time to spend on patient education,29
and not surprisingly, a gap often exists between what patients actually understand and what health care professionals expect them to. This is further highlighted by the significant proportion of women (23 out of 89) whose physician documented a discussion about the abnormal test result that did not recall this discussion. If we make the reasonable assumption that a discussion did indeed occur for these women, our findings suggest that not all patients can recall the contents of a discussion with a physician. Strategies advocated by health literacy experts,30 – 32
which include asking patients to describe their understanding after information is delivered to them, may be helpful. Providing some memory aid, such as written instructions may also prove useful. Other strategies may include the deployment of advanced patient-doctor communication systems that allow physicians and patients to discuss with each other test results and follow-up plans via secured e-mail and to set electronic reminders to ensure the follow-up plan is carried out.
Second, we found that documentation of the follow-up plan by the treating physician was associated with the appropriate follow-up of test results. While documentation may simply be a marker for the occurrence of a discussion between the patient and doctor regarding the abnormal mammogram result, there is evidence to suggest that documentation itself is an important element of quality care. This insight is reinforced by the literature on error prevention.33
Documentation can be understood as a systemic approach to overcome the momentary oversights that can lead to significant poor outcomes in complex organizations.34
It is interesting to note that documentation was predictive of the favorable outcome after controlling for whether the patient reports being told about the follow-up plan. This suggests that documentation might serve as a “back-up” reminder for the physician to ensure the appropriate execution of the follow-up plan, as well as a way for members of the care team to communicate with each other. Strategies to improve documentation of the follow-up plan should focus on making documentation as easy as possible for the physician, and may include the use of standardized templates within the electronic medical record.
Our results also offer insight on other strategies to address the quality problem in result follow-up. For example, new legislation now mandates that all Medicaid patients who undergo a mammogram receive their results in writing. A recent study performed by Priyanath, however, suggests that this strategy may be inadequate.35
While Priyanath showed that the new legislation increased patients’ satisfaction regarding the speed of mammography result reporting, patients were still no more likely to remember the appropriate follow-up plan. This is consistent with our results, which suggest that the provision of the mammogram results to the patient may not, by itself, be sufficient to ensure the execution of the appropriate follow-up plan; women in our study who were given the mammography results to take home with them and those who received the results within 1 week were not more likely to receive the appropriate follow-up care (result to take home: OR = 1.30, P
= .57; result within 1 week, OR = 1.18, P
= .73). Taken together, these 2 studies potentially underline the role clinicians play in helping patients interpret abnormal test results and creating follow-up plans that are readily understood by patients. While the negative findings from our study should be interpreted in light of its relatively small sample size, they lend further strength to Priyanath's results.
This study has several limitations. This is an observational study whose results could have been affected by volunteer bias. The number of subjects included in this study is relatively small, and therefore the study might have been underpowered to detect other factors predictive of good follow-up care. Specifically, our power to statistically identify (at P
< .05) a risk factor for receiving adequate follow-up at an odds ratio of 2.25 is only 57%.a
This may explain why some of the factors previously cited as predictors of follow-up, such as race and number of prior mammograms, were not found to be significant predictors in this study. Other potentially important physician factors, such as the amount of time physicians spent on educating patients, were not measured in this study and would merit investigation in future studies. The length of follow-up period common to all women was only 7 months, and it is unclear whether more women would have been classified as having received the appropriate care if we had observed them for longer periods. However, other studies have reported similar rates of appropriate follow-up care.20,22
This study only focused on the follow-up of abnormal mammograms requiring further short-term follow-up, and its findings may not be generalizable to other types of follow-up in health care. These findings might not readily translate to the follow-up of patients with symptoms, or in patients seen in nongeneral medicine clinics.
In summary, follow-up of abnormal results represents a challenge in the outpatient setting, where follow-up actions often have to be performed in the future. We found that up to one-third of women with abnormal mammograms requiring short-term follow-up do not receive the appropriate follow-up care. We also found that documentation of the follow-up plan by the physician and the awareness of the follow-up plan by the patient are independently associated with the delivery of appropriate follow-up care. Our health care system needs to adopt better strategies to ensure that appropriate follow-up of abnormal tests occurs. We believe that these strategies need to address how patients and physicians communicate with each other about abnormal test results. Further research is needed to determine whether better result management systems can reduce the present quality gap.